Provider Demographics
NPI:1891733853
Name:MIRMAN, MORTON CHESTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:MORTON
Middle Name:CHESTER
Last Name:MIRMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:CHET
Other - Last Name:MIRMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:910 SKOKIE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-4013
Mailing Address - Country:US
Mailing Address - Phone:847-209-1515
Mailing Address - Fax:847-291-0576
Practice Address - Street 1:910 SKOKIE BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-4013
Practice Address - Country:US
Practice Address - Phone:847-209-1515
Practice Address - Fax:847-291-0576
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003339103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL884069OtherFIRST HEALTH COVENTRY
ILL58293Medicare ID - Type UnspecifiedGROUP 239060